Qualtrics CMO and Former Cleveland Clinic CXO Adrienne Boissy, MD

Digital Health

UCSF Study: EHR Design and Provider Behavior

A new study published in JAMIA gave us a good look at how EHR design – particularly choice architecture – can significantly influence provider behavior.

University of California, San Francisco researchers investigated several workflows at a UCSF medical center where the existing choice architecture was potentially nudging providers toward waste or misuse.

The first workflow involved ordering “free phenytoin” levels, a costly send-out test that often results in delayed care for patients, despite a readily available “total phenytoin level” being sufficient in most cases.

• The researchers hypothesized that the EHR alphabetically presenting “free phenytoin” before “total phenytoin” to providers searching for “phenytoin level” was influencing them to order the more costly and time-consuming test.

• They then replaced the alphabetical structure with an order panel presented to any provider searching for “phenytoin” that gave an explanation of the circumstances when each test is appropriate.

• They simultaneously nudged providers toward the “total phenytoin” test that is “almost always correct” by making it the default selection. The intervention improved the rate of correct test orders from 92% to 100%.

Another workflow the researchers examined was the prescription of benzodiazepines for procedural anxiety. The EHR originally set the default quantity for benzodiazepines to the same quantity needed for patients routinely taking the medications for a chronic disease, therefore nudging providers to overprescribe the pills.

• The researchers created a new order called “Lorazepam (Ativan) tablet 0.5 mg for imaging/procedure” specifically for imaging patients with a default quantity of two tablets with zero refills.

• The new order included a default comment “for anxiety (prior to imaging study or procedure)” to nudge providers toward the appropriate quantity. This intervention was also successful.

Despite the success at UCSF, the authors emphasized that organizations must balance the potential benefits of any EHR improvements against their implementation costs. The phenytoin nudge consumed six hours of implementation time and the Lorazepam nudge took almost 3x that long, which might make other investments more worthwhile depending on the org.

The Takeaway

Although choice architecture is the name of the game for pretty much every product and design team, it’s doubly important when the choices directly impact people’s health. This study was great at wrapping numbers around how this plays out in a medical setting, and it was also interesting to see the cost-benefit analysis that still takes place when deciding whether to implement a solution that clearly improves outcomes.

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The Wire

• PHE Ending in May: Well… the day has finally come. Earlier this week, the Biden administration announced plans to terminate the public health emergency on May 11, ushering in a new chapter in the government’s pandemic response. KFF put together a detailed look at all of the provisions getting unwound, including hospital incentives for treating COVID patients, relaxed state licensure requirements, and cost sharing for at-home tests. It’s worth noting that the recent omnibus spending package addressed (for now) a few of the larger issues, such as extending telehealth flexibilities and hospital-at-home waivers through 2024.

• Health Gorilla Pharmacy Data: Health Gorilla’s platform just took a major step forward with the launch of Pharmacy Data, which allows providers to view complete patient medication histories. Pharmacy Data is powered by a new partnership with DrFirst that integrates prescribing data, pharmacy dispensing data, and PBM claims into longitudinal medication records that Health Gorilla then processes to surface insights and enable more informed treatment decisions.

• App Store Gatekeepers: Mobile apps are one of the most popular ways for consumers to access digital health solutions, which raises some interesting questions about whether Google and Apple’s app stores should be able to act as gatekeepers to medical tools… especially as they develop their own competing health products. A new paper in Nature does a great job dissecting the nuances of these conflicts of interest, while also exploring how recent EU legislation might serve as a blueprint for other regions.

• Cedars-Sinai & Tia Team Up: Tia is teaming up with Cedars-Sinai health system to open clinics across the Los Angeles area and serve more than 100k women with a hybrid model for primary care, mental health, and OB-GYN services. The partnership will combine Tia’s primary care with Cedars’ specialists as both organizations share clinical leadership, co-develop clinical protocols, and contribute financially to the new clinics.

• 2022 Hospital Margins: Kaufman Hall’s latest National Flash report revealed the unfortunately unsurprising news that nearly half of hospitals finished 2022 in the red, despite slight margin gains in December (up to 0.2% from -0.2% in November). Although last year was the worst year for hospitals since the start of the pandemic, Kaufman Hall outlined how better workforce management and stabilizing supply channels could help lead to a rosier financial outlook for 2023.

• Aluna Secures $15M: Asthma monitoring startup Aluna raised $15M in Series B funding to continue developing its FDA-cleared spirometer device that lets people see how they respond to medications in real time. Patients breathe into the Aluna device to visualize their lung function within an integrated app that shares the data with their physician, allowing them to be reimbursed through RPM codes.

• Innovaccer + Prisma: Innovaccer hasn’t missed a beat expanding despite its recent headcount reduction, adding South Carolina’s largest non-profit health system Prisma Health to its Health Cloud partner roster. The move will allow the 18-hospital system and its inVio clinically integrated network to synthesize their various EHRs into a unified record with access to Innovaccer’s physician engagement, care management, and population health tools. 

• Virtual First Health Plan: Blue Shield of California is building on new partnerships with Accolade and TeleMed2U to release a Virtual Blue health plan for virtual-first primary and specialty care. Virtual Blue goes into effect on April 1, providing members with virtual care at no OOP cost (primary, behavioral, specialty), in-person care through the plan’s PPO network, around-the-clock acute care, and an included vitals kit (thermometer, scale, blood pressure cuff).

• Behavioral Flag Disparities: New research in JAMA found that EHR behavioral flags designed to help prevent violence against physicians might also prevent some patients from receiving proper care. After analyzing ED visit data from 195k patients (683 w/ behavioral flags), researchers found that flagged Black patients saw significantly worse care than flagged White patients, such as longer wait times (28 min vs. 18 min), less lab tests (57% vs. 63%), and less imaging exams (37% vs. 54%).

• CVS & RUSH ACO Alliance: CVS Health is partnering with Rush University System for Health to expand local Medicare patients’ access to RUSH clinical services. The collaboration allows patients at ACO REACH-participating MinuteClinics to receive follow-up and specialty care at RUSH locations, as well as customized support such as home-based care and transportation to annual wellness visits.

• WellSet Self-Care Benefits: Holistic digital health studio WellSet unveiled a new mental health benefit designed to help employees address burnout using alternative evidence-based practices. The WellSet platform provides unlimited access to thousands of classes across more than 20 practices such as yoga and mindfulness training, as well as some less-popular-but-fun-sounding treatments like Acupressure, Self-Hypnosis, and EFT/Tapping.

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